Certificate of Coverage
YOUR BENEFIT PLAN WA State Health Care Authority PEBB Class 1 Retiree Term Life Plan: WA State Health Care Authority PEBB and WA State Health Care Authority SEBB employees enrolled in Basic Life Insurance who meet qualifications for enrollment in PEBB retiree insurance coverage on or after January 1, 2017; and Retirees who elected to move from the Policyholder’s $3,000 benefit plan to this Class 1 Retiree Term Life Plan during the 2016 open enrollment period Class 2 Legacy Retiree Term Life Plan: Retirees enrolled in the Policyholder’s $3,000 benefit plan prior to January 1, 2017 who did not move to the Policyholder’s new Class 1 Retiree Term Life Plan during the 2016 open enrollment period Retiree Term Life Insurance Certificate Date: January 1, 2024 Certificate Number 19
WA State Health Care Authority PEBB 626 8th Avenue SE P.O. Box 42684 Olympia, WA 98504-2684 TO RETIRED EMPLOYEES: All of us appreciate the protection and security insurance provides. This certificate describes the benefits that are available to you. We urge you to read it carefully. WA State Health Care Authority PEBB
Metropolitan Life Insurance Company 200 Park Avenue, New York, New York 10166 CERTIFICATE OF INSURANCE Metropolitan Life Insurance Company (“MetLife”), a stock company, certifies that You are insured for the benefits described in this certificate, subject to the provisions of this certificate. This certificate is issued to You under the Group Policy and it includes the terms and provisions of the Group Policy that describe Your insurance. PLEASE READ THIS CERTIFICATE CAREFULLY. This certificate is part of the Group Policy. The Group Policy is a contract between MetLife and the Policyholder and may be changed or ended without Your consent or notice to You. Policyholder: WA State Health Care Authority PEBB Group Policy Number: 164995-1-G Type of Insurance: Term Life Insurance MetLife Toll Free Number(s): For Claim Information FOR LIFE CLAIMS: 1-866-548-7139 THIS CERTIFICATE ONLY DESCRIBES TERM LIFE INSURANCE. IN THE EVENT THERE IS A CONFLICT BETWEEN LANGUAGE APPEARING IN THE GROUP POLICY AND THE CERTIFICATE, THE LANGUAGE IN THE CERTIFICATE WILL CONTROL. FOR CALIFORNIA RESIDENTS: REVIEW THIS CERTIFICATE CAREFULLY. IF YOU ARE 65 OR OLDER ON YOUR EFFECTIVE DATE OF THIS CERTIFICATE, YOU MAY RETURN IT TO US WITHIN 30 DAYS FROM THE DATE YOU RECEIVE IT AND WE WILL REFUND ANY PREMIUM YOU PAID. IN THIS CASE, THIS CERTIFICATE WILL BE CONSIDERED TO NEVER HAVE BEEN ISSUED. FOR FLORIDA RESIDENTS: THE BENEFITS OF THE POLICY PROVIDING YOUR COVERAGE ARE GOVERNED PRIMARILY BY THE LAW OF A STATE OTHER THAN FLORIDA. For Idaho Residents: TEN DAY RIGHT TO EXAMINE CERTIFICATE: You may return the certificate to Us within 10 days from the date You receive it. If You return it within the 10 day period, the certificate will be considered never to have been issued. We will refund any premium paid after We receive Your notice of cancellation. FOR MARYLAND RESIDENTS: THE GROUP INSURANCE POLICY PROVIDING COVERAGE UNDER THIS CERTIFICATE WAS ISSUED IN A JURISDICTION OTHER THAN MARYLAND AND MAY NOT PROVIDE ALL THE BENEFITS REQUIRED BY MARYLAND LAW. GCERT2024-WSHCA-WA-LIFE-RETIREE1 1
For Residents of North Dakota: If You are not satisfied with Your Certificate, You may return it to Us within 20 days after You receive it, unless a claim has previously been received by Us under Your Certificate. We will refund within 30 days of Our receipt of the returned Certificate any Premium that has been paid and the Certificate will then be considered to have never been issued. You should be aware that, if You elect to return the Certificate for a refund of premiums, losses which otherwise would have been covered under Your Certificate will not be covered. WE ARE REQUIRED BY STATE LAW TO INCLUDE THE NOTICE(S) WHICH APPEAR ON THIS PAGE AND IN THE NOTICE(S) SECTION WHICH FOLLOWS THIS PAGE. PLEASE READ THE(SE) NOTICE(S) CAREFULLY. Jeannette N. Pina Michel Khalaf Vice President and Secretary President GCERT2024-WSHCA-WA-LIFE-RETIREE1 2
NOTICE FOR RESIDENTS OF TEXAS Have a complaint or need help? If you have a problem with a claim or your premium, call your insurance company or HMO first. If you can't work out the issue, the Texas Department of Insurance may be able to help. Even if you file a complaint with the Texas Department of Insurance, you should also file a complaint or appeal through your insurance company or HMO. If you don't, you may lose your right to appeal. Metropolitan Life Insurance Company To get information or file a complaint with your insurance company or HMO: Call: Corporate Consumer Relations Department at 1-800-438-6388 Toll-free: 1-800-438-6388 Email: [email protected] Mail: Metropolitan Life Insurance Company 700 Quaker Lane 2nd Floor Warwick, RI 02886 The Texas Department of Insurance To get help with an insurance question or file a complaint with the state: Call with a question: 1-800-252-3439 File a complaint: www.tdi.texas.gov Email: [email protected] Mail: MC 111-1A, P.O. Box 149091, Austin, TX 78714-9091 ¿Tiene una queja o necesita ayuda? Si tiene un problema con una reclamación o con su prima de seguro, llame primero a su compañía de seguros o HMO. Si no puede resolver el problema, es posible que el Departamento de Seguros de Texas (Texas Department of Insurance, por su nombre en inglés) pueda ayudar. Aun si usted presenta una queja ante el Departamento de Seguros de Texas, también debe presentar una queja a través del proceso de quejas o de apelaciones de su compañía de seguros o HMO. Si no lo hace, podría perder su derecho para apelar. Metropolitan Life Insurance Company Para obtener información o para presentar una queja ante su compañía de seguros o HMO: Llame a: Departamento de Relaciones Corporativas del Consumidor al 1-800-438-6388 GCERT2024-WSHCA-WA-LIFE-RETIREE1 3
Teléfono gratuito: 1-800-438-6388 Correo electrónico: [email protected] Dirección postal: Metropolitan Life Insurance Company 700 Quaker Lane 2nd Floor Warwick, RI 02886 El Departamento de Seguros de Texas Para obtener ayuda con una pregunta relacionada con los seguros o para presentar una queja ante el estado: Llame con sus preguntas al: 1-800-252-3439 Presente una queja en: www.tdi.texas.gov Correo electrónico: [email protected] Dirección postal: MC 111-1A, P.O. Box 149091, Austin, TX 78714-9091 GCERT2024-WSHCA-WA-LIFE-RETIREE1 4
NOTICE FOR RESIDENTS OF ARKANSAS If You have a question concerning Your coverage or a claim, first contact the Policyholder or group account administrator. If, after doing so, You still have a concern, You may call the toll free telephone number shown on the Certificate Face Page. Policyholders have the right to file a complaint with the Arkansas Insurance Department (AID). You may call AID to request a complaint form at (800) 852-5494 or (501) 371-2640 or write the Department at: Arkansas Insurance Department Consumer Services Division 1 Commerce Way, Suite 102 Little Rock, Arkansas 72202 GCERT2024-WSHCA-WA-LIFE-RETIREE1 5
NOTICE FOR RESIDENTS OF CALIFORNIA IMPORTANT NOTICE TO OBTAIN ADDITIONAL INFORMATION, OR TO MAKE A COMPLAINT, CONTACT THE POLICYHOLDER OR METLIFE AT: METROPOLITAN LIFE INSURANCE COMPANY ATTN: CONSUMER RELATIONS DEPARTMENT 500 SCHOOLHOUSE ROAD JOHNSTOWN, PA 15904 1-800-438-6388 IF, AFTER CONTACTING THE POLICYHOLDER AND/OR METLIFE, YOU FEEL THAT A SATISFACTORY SOLUTION HAS NOT BEEN REACHED, YOU MAY FILE A COMPLAINT WITH THE CALIFORNIA DEPARTMENT OF INSURANCE DEPARTMENT AT: DEPARTMENT OF INSURANCE CONSUMER SERVICES 300 SOUTH SPRING STREET LOS ANGELES, CA 90013 WEBSITE: http://www.insurance.ca.gov/ 1-800-927-4357 (within California) 1-213-897-8921 (outside California) GCERT2024-WSHCA-WA-LIFE-RETIREE1 6
NOTICE FOR RESIDENTS OF CALIFORNIA If Your certificate includes an exclusion for the voluntary intake or use by any means of any drug, medication or sedative, unless it is taken or used as prescribed by a Physician (or a similar exclusion), We will adjudicate your claim as follows: We will exclude any Covered Loss as a consequence of being under the influence of any intoxicant or controlled substance unless administered on the advice of a Physician. GCERT2024-WSHCA-WA-LIFE-RETIREE1 7
NOTICE FOR RESIDENTS OF GEORGIA IMPORTANT NOTICE The laws of the state of Georgia prohibit insurers from unfairly discriminating against any person based upon their status as a victim of family violence. GCERT2024-WSHCA-WA-LIFE-RETIREE1 8
NOTICE FOR RESIDENTS OF IDAHO If You have a question concerning Your coverage or a claim, You may call the toll free telephone number shown on the Certificate Face Page. If You are still concerned after contacting MetLife, You should feel free to contact: Idaho Department of Insurance Consumer Affairs rd 700 West State Street, 3 Floor PO Box 83720 Boise, Idaho 83720-0043 1-800-721-3272 (for calls placed within Idaho) or 208-334-4250 or www.DOI.Idaho.gov GCERT2024-WSHCA-WA-LIFE-RETIREE1 9
NOTICE FOR RESIDENTS OF ILLINOIS IMPORTANT NOTICE To make a complaint to MetLife, You may write to: MetLife 200 Park Avenue New York, New York 10166 The address of the Illinois Department of Insurance is: Illinois Department of Insurance Public Services Division Springfield, Illinois 62767 GCERT2024-WSHCA-WA-LIFE-RETIREE1 10
NOTICE FOR RESIDENTS OF INDIANA Questions regarding your policy or coverage should be directed to: Metropolitan Life Insurance Company 1-800-438-6388 If you (a) need the assistance of the government agency that regulates insurance; or (b) have a complaint you have been unable to resolve with your insurer you may contact the Department of Insurance by mail, telephone or email: State of Indiana Department of Insurance Consumer Services Division 311 West Washington Street, Suite 300 Indianapolis, Indiana 46204 Consumer Hotline: (800) 622-4461; (317) 232-2395 Complaint can be filed electronically at www.in.gov/idoi GCERT2024-WSHCA-WA-LIFE-RETIREE1 11
NOTICE FOR RESIDENTS OF TEXAS THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM. GCERT2024-WSHCA-WA-LIFE-RETIREE1 12
NOTICE FOR RESIDENTS OF UTAH Notice of Protection Provided by Utah Life and Health Insurance Guaranty Association This notice provides a brief summary of the Utah Life and Health Insurance Guaranty Association ("the Association") and the protection it provides for policyholders. This safety net was created under Utah law, which determines who and what is covered and the amounts of coverage. The Association was established to provide protection in the unlikely event that your life, health, or annuity insurance company becomes financially unable to meet its obligations and is taken over by its insurance regulatory agency. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Utah law, with funding from assessments paid by other insurance companies. The basic protections provided by the Association are: Life Insurance o $500,000 in death benefits o $200,000 in cash surrender or withdrawal values Health Insurance o $500,000 in hospital, medical and surgical insurance benefits o $500,000 in long-term care insurance benefits o $500,000 in disability income insurance benefits o $500,000 in other types of health insurance benefits Annuities o $250,000 in withdrawal and cash values The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $500,000. Special rules may apply with regard to hospital, medical and surgical insurance benefits. Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract. Coverage is conditioned on residency in this state and there are substantial limitations and exclusions. For a complete description of coverage, consult Utah Code, Title 3 lA, Chapter 28. Insurance companies and agents are prohibited by Utah law to use the existence of the Association or its coverage to encourage you to purchase insurance. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between Utah law and this notice, Utah law will control. To learn more about the above protections, as well as protections relating to group contracts or retirement plans, please visit the Association's website at www.utlifega.org or contact: Utah Life and Health Insurance Guaranty Assoc. Utah Insurance Department 60 East South Temple, Suite 500 3110 State Office Building Salt Lake City UT 84111 Salt Lake City UT 84114-6901 (801) 320-9955 (801) 538-3800 A written complaint about misuse of this Notice or the improper use of the existence of the Association may be filed with the Utah Insurance Department at the above address. GCERT2024-WSHCA-WA-LIFE-RETIREE1 13
NOTICE FOR RESIDENTS OF VIRGINIA IMPORTANT INFORMATION REGARDING YOUR INSURANCE In the event You need to contact someone about this insurance for any reason please contact Your agent. If no agent was involved in the sale of this insurance, or if You have additional questions You may contact the insurance company issuing this insurance at the following address and telephone number: MetLife 200 Park Avenue New York, New York 10166 Attn: Corporate Consumer Relations Department To phone in a claim related question, You may call Claims Customer Service at: 1-800-275-4638 If You have been unable to contact or obtain satisfaction from the company or the agent, You may contact the Virginia State Corporation Commission’s Bureau of Insurance at: Bureau of Insurance Life and Health Division P.O. Box 1157 Richmond, VA 23218-1157 1-804-371-9691 - phone 1-877-310-6560 - toll-free 1-804-371-9944 - fax www.scc.virginia.gov - web address [email protected] - email Written correspondence is preferable so that a record of Your inquiry is maintained. When contacting Your agent, company or the Bureau of Insurance, have Your policy number available. GCERT2024-WSHCA-WA-LIFE-RETIREE1 14
NOTICE FOR RESIDENTS OF WEST VIRGINIA FREE LOOK PERIOD: If You are not satisfied with Your certificate, You may return it to Us within 10 days after You receive it, unless a claim has previously been received by Us under Your certificate. We will refund within 10 days of our receipt of the returned certificate any Premium that has been paid and the certificate will then be considered to have never been issued. You should be aware that, if You elect to return the certificate for a refund of premiums, losses which otherwise would have been covered under Your certificate will not be covered. GCERT2024-WSHCA-WA-LIFE-RETIREE1 15
NOTICE FOR RESIDENTS OF WISCONSIN KEEP THIS NOTICE WITH YOUR INSURANCE PAPERS PROBLEMS WITH YOUR INSURANCE? - If You are having problems with Your insurance company or agent, do not hesitate to contact the insurance company or agent to resolve Your problem. MetLife Attn: Corporate Consumer Relations Department 200 Park Avenue New York, New York 10166 1-800-438-6388 You can also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency which enforces Wisconsin’s insurance laws, and file a complaint. You can contact the OFFICE OF THE COMMISSIONER OF INSURANCE by contacting: Office of the Commissioner of Insurance Complaints Department P.O. Box 7873 Madison, WI 53707-7873 1-800-236-8517 outside of Madison or 608-266-0103 in Madison. GCERT2024-WSHCA-WA-LIFE-RETIREE1 16
NOTICE This non-insurance benefit does not constitute an insurance funded prearrangement contract, pursuant to RCW 18.39.255. Employees who become insured for MetLife Retiree Term Life Insurance under the Group Policy are eligible to receive discounts of up to 10% off the service provider’s standard price for certain funeral services including funeral, cremation and cemetery products and services provided by a third party national network of funeral and funeral planning providers while such insurance remains in effect. Employees who become insured for MetLife Retiree Term Life Insurance will also have access to funeral planning resources including funeral planning tools and concierge services provided by the same national network of providers. MetLife has arranged for these services and discounts to be provided to Employees and their spouses for no additional premium. GCERT2024-WSHCA-WA-LIFE-RETIREE1 17
TABLE OF CONTENTS Section Page CERTIFICATE FACE PAGE .............................................................................................................................. 1 NOTICES ......................................................................................................................................................... 17 SCHEDULE OF BENEFITS ............................................................................................................................. 19 DEFINITIONS .................................................................................................................................................. 21 ELIGIBILITY PROVISIONS: INSURANCE FOR YOU ..................................................................................... 23 PEBB Eligible ............................................................................................................................................... 23 Date You Are Eligible for Insurance ............................................................................................................. 23 Enrollment Process ...................................................................................................................................... 23 Date Your Insurance Takes Effect ............................................................................................................... 23 Date Insurance Ends .................................................................................................................................... 24 LIFE INSURANCE: FOR YOU ......................................................................................................................... 25 LIFE INSURANCE: CONVERSION OPTION FOR YOU ................................................................................. 26 FILING A CLAIM: CLAIMS FOR LIFE INSURANCE BENEFITS .................................................................... 28 GENERAL PROVISIONS ................................................................................................................................. 29 Assignment ................................................................................................................................................... 29 Beneficiary .................................................................................................................................................... 29 Entire Contract .............................................................................................................................................. 29 Incontestability: Statements Made by You ................................................................................................... 29 Misstatement of Age ..................................................................................................................................... 30 Conformity with Law ..................................................................................................................................... 30 GCERT2024-WSHCA-WA-LIFE-RETIREE1 18
SCHEDULE OF BENEFITS This schedule shows the benefits that are available under the Group Policy. You will only be insured for the benefits: for which You become and remain eligible; which You elect, if subject to election; and which are in effect. The amount of Insurance that We will pay for any insurance to which You make premiums will be decreased by the amount of Your premiums due and unpaid to Us for that insurance. How We Will Pay Benefits Unless the Beneficiary requests payment by check, when the Certificate states that We will pay benefits in "one sum", “lump sum” or a "single sum", We may pay the full benefit amount: by check; by establishing an account that earns interest and provides the Beneficiary with immediate access to the full benefit amount; or by any other method that provides the Beneficiary with immediate access to the full benefit amount. Other modes of payment may be available upon request. For details, call Our toll free number shown on the Certificate Face Page. BENEFIT BENEFIT AMOUNTS AND HIGHLIGHTS Life Insurance For You Class 1 Retiree Term Life Plan: WA State Health Care Authority PEBB and WA State Health Care Authority SEBB employees enrolled in Basic Life Insurance who meet qualifications for enrollment in PEBB retiree insurance coverage on or after January 1, 2017; and Retirees who elected to move from the Policyholder’s $3,000 benefit plan to this Class 1 Retiree Term Life Plan during the 2016 open enrollment period. ........................................................ An amount, elected by You on the . date You retire, which is a multiple of $5,000 Minimum Life Benefit ................................................... $5,000 Maximum Life Benefit .................................................. $20,000 GCERT2024-WSHCA-WA-LIFE-RETIREE1 19
SCHEDULE OF BENEFITS (continued) Class 2 Legacy Retiree Term Life Plan: Retirees enrolled in the Policyholder’s $3,000 benefit plan prior to January 1, 2017 who did not move to the Policyholder’s new Class 1 Retiree Term Life Plan during the 2016 open enrollment period. ........................................................................... $3,000 Class 2 Retired Employees - If You are age 65 or Older On Your 65th birthday, the amount of Your Insurance will be reduced to $2,100. On Your 70th birthday, the amount of such insurance will be reduced to $1,800. ESTATE RESOLUTION SERVICES The following Estate Resolution Services are provided at no additional cost to individuals insured for Group Retiree Term Life Insurance coverage as described below. If You are eligible to receive these Estate Resolution Services and You, Your Spouse, or State-Registered Domestic Partner (for the Will Preparation Service) or You, Your Spouse, State-Registered Domestic Partner, or a Beneficiary (for the Probate Service) would like to speak with a representative from MetLife Legal Plans or get the name of a Plan Attorney that you can speak with about these Services, please call (800) 821-6400. Will Preparation Service If You elect Group Retiree Term Life Insurance coverage, a Will Preparation Service (the “Service”) will be made available to You, through a MetLife affiliate (the “Affiliate”), while Your Group Retiree Term Life Insurance coverage is in effect. This Service will be made available at no cost to You. It enables You to have a will prepared for You and Your Spouse or State-Registered Domestic Partner free of charge by attorneys designated by the Affiliate. If You have a will prepared by an attorney not designated by the Affiliate, You must pay for the attorney’s services directly. Upon Proof of such payment, You will be reimbursed for the attorney’s services in an amount equal to the lesser of the amount You paid for the attorney’s services and the amount customarily reimbursed for such services by the Affiliate. Probate Service If You become insured for Group Retiree Term Life Insurance coverage and You, Your Spouse, or State-Registered Domestic Partner die while such Group Retiree Term Life Insurance coverage is in effect, a probate benefit (the “Benefit”) will be made available to Your estate in the event of Your death or to Your Spouse or State-Registered Domestic Partner's estate in the event of Your Spouse or State-Registered Domestic Partner's death. Such benefit will be made available through a MetLife affiliate (“Affiliate”). The Benefit provides for certain probate services to be made available, free of charge by attorneys designated by the Affiliate. If probate services are provided by an attorney not designated by the Affiliate, the estate of the deceased must pay for those attorney’s services directly. Upon Proof of such payment, the estate of the deceased will be reimbursed for the attorney’s services in an amount equal to the lesser of the amount such estate paid for the attorney’s services and the amount customarily reimbursed for such services by the Affiliate. This Benefit will be provided at no cost to You and will end on the date Your Group Retiree Term Life Insurance coverage ends. GCERT2016-WSHCA-WA-LIFE-RETIREE1 20
DEFINITIONS As used in this certificate, the terms listed below will have the meanings set forth below. When defined terms are used in this certificate, they will appear with initial capitalization. The plural use of a term defined in the singular will share the same meaning. Basic Life Insurance means Your basic life insurance coverage as an employee insured under the WA State Health Care Authority PEBB or WA State Health Care Authority SEBB group policy issued by Us. Beneficiary means the person(s) to whom We will pay insurance as determined in accordance with the GENERAL PROVISIONS section. Certificateholder means a Class 1 Retiree or Class 2 Legacy Retiree who is insured under the Group Policy. Employer Group for the public employees’ benefits board program means a county, municipality, political subdivision, the Washington health benefit exchange, tribal government, or employee organizations representing state civil service employees obtaining employee benefits through a contractual agreement with the Policyholder to participate in benefit plans. Employer Group for the school employees’ benefits board program means an employee organization representing school employees and a tribal school obtaining employee benefits through a contractual agreement with the Health Care Authority to participate in benefit plans. Employing Agency means a division, department, or separate agency of state government, including an institution of higher education; a county, municipality, or other political subdivision; and a tribal government covered by state statute. It also includes Washington health benefit exchange and employee organizations representing state civil service employees. Policyholder means WA State Health Care Authority PEBB. Proof means Written evidence satisfactory to Us that a person has satisfied the conditions and requirements for any benefit described in this certificate. When a claim is made for any benefit described in this certificate, Proof must establish: the nature and extent of the loss or condition; Our obligation to pay the claim; and the claimant’s right to receive payment. Proof must be provided at the claimant’s expense. Retiree-Paid Insurance means insurance for which the Policyholder requires You to pay any part of the premium. Retiree-Paid Insurance includes: Term Life Insurance. Signed means any symbol or method executed or adopted by a person with the present intention to authenticate a record, which is on or transmitted by paper or electronic media which is acceptable to Us and consistent with applicable law. Spouse means Your legal spouse. State-Registered Domestic Partner as defined in state statute and substantially equivalent legal unions from jurisdictions as defined in Washington state statute. We, Us and Our mean MetLife. GCERT2024-WSHCA-WA-LIFE-RETIREE1 21
DEFINITIONS (continued) Written or Writing means a record which is on or transmitted by paper or electronic media which is acceptable to Us and consistent with applicable law. You and Your means: prior to the date insurance takes effect under this certificate, an eligible employee who participated in PEBB or SEBB Life insurance as an employee and meets qualifications for PEBB retiree insurance coverage; after the date insurance takes effect under this certificate, the Certificateholder. GCERT2024-WSHCA-WA-LIFE-RETIREE1 22
ELIGIBILITY PROVISIONS: INSURANCE FOR YOU PEBB ELIGIBLE RETIREE Class 1 Retiree Term Life Plan: WA State Health Care Authority PEBB and WA State Health Care Authority SEBB employees enrolled in Basic Life Insurance who meet qualifications for enrollment in PEBB retiree insurance coverage on or after January 1, 2017; and Retirees who elected to move from the Policyholder’s $3,000 benefit plan to this Class 1 Retiree Term Life Plan during the 2016 open enrollment period. Class 2 Legacy Retiree Term Life Plan: Retirees enrolled in the Policyholder’s $3,000 benefit plan prior to January 1, 2017 who did not move to the Policyholder’s new Class 1 Retiree Term Life Plan during the 2016 open enrollment period. You are eligible for insurance if You were covered for insurance on the day immediately preceding the date Your PEBB retiree insurance coverage begins. DATE YOU ARE ELIGIBLE FOR INSURANCE You may only become eligible for the insurance available for Your eligible class as shown in the SCHEDULE OF BENEFITS. If You are a PEBB Eligible Retiree on January 1, 2024, You will be eligible for the insurance described in this certificate on that date. If You become a PEBB Eligible Retiree after January 1, 2024, You will be eligible for the insurance described in this certificate on the date You become a PEBB Eligible Retiree. ENROLLMENT PROCESS If You are eligible as described in the section of this certificate titled PEBB ELIGIBLE RETIREE, You may enroll by completing the required forms and submitting them to the Policyholder. The required forms must be received by the Policyholder within the required time frame. You must elect Retiree Term Life Insurance no later than 60 days after the date Your Basic Life Insurance ends or for an official leaving public office, no later than 60 days after leaving public office. If the Policyholder does not receive the required enrollment forms electing Retiree Term Life Insurance within the required 60 day time frame, You cannot elect Retiree Term Life Insurance at a later date unless Your Supplemental Life Insurance premiums are being waived under the terms of the WA State Health Care Authority PEBB or WA State Health Care Authority SEBB certificates for Supplemental Life Insurance. If Your Supplemental Life Insurance premiums are being waived under the terms of the Policyholder’s certificate for Supplemental Life Insurance, You must elect Retiree Term Life Insurance no later than 60 days after the date Your waiver of premium benefit ends. We will notify You of the cost of the insurance You elect. You must pay the premium for such insurance. DATE YOUR INSURANCE TAKES EFFECT Rules for Retiree-Paid Insurance Class 1 Retiree Term Life Plan: If You are eligible and elect Retiree Term Life Insurance, such insurance will take effect on the first day of the month following the date Your Basic Life Insurance ends or the first day of the month following the date Your waiver of premium benefit ends. If You return to work and regain eligibility for enrollment under the WA State Health Care Authority PEBB or WA State Health Care Authority SEBB Basic Life Insurance Group Policy, You may choose to maintain Your Retiree Term Life Plan; however, You must continue to pay the cost of such insurance. If you choose not to maintain Your Retiree Term Life Plan enrollment, You may elect to re-enroll in such insurance provided We receive Your enrollment forms no later than 60 days after the date Your Basic Life Insurance ends. GCERT2024-WSHCA-WA-LIFE-RETIREE1 23
ELIGIBILITY PROVISIONS: INSURANCE FOR YOU (continued) Class 2 Legacy Retiree Term Life Plan: Your Legacy Retiree Term Life Plan will become effective on January 1, 2017. If You return to work and regain eligibility for enrollment under the WA State Health Care Authority PEBB or WA State Health Care Authority SEBB Basic Life Insurance Group Policy, You may choose to maintain Your Legacy Retiree Term Life Plan; however, You must continue to pay the cost of such insurance. If You choose not to maintain Your Legacy Retiree Term Life Plan enrollment, You may elect to re-enroll in such insurance provided Your enrollment form is received no later than 60 days after the date Your Basic Life Insurance ends. Please note that once You drop Your Legacy Retiree Term Life Plan, any future re-enrollment would be in the MetLife Retiree Term Life Plan, following the provisions outlined for Class 1 Retiree Term Life as outlined in this certificate. Increase in Insurance: Class 1 Benefit and Class 2 Benefit You are not eligible to increase Your amount of Life insurance after the date You retire. Decrease in Insurance: Class 1 Benefit If You make a Written request to decrease Your insurance, that decrease will take effect as of the first day of the month following the date We receive Your Written request. Decrease in Insurance: Class 2 Benefit You are not eligible to decrease Your amount of Life insurance after the effective date of such insurance. DATE INSURANCE ENDS Your insurance will end on the earliest of: 1. the date the Group Policy ends; or 2. the last day of the calendar month insurance ends for Your class; or 3. the last day of the calendar month for which the premium has been paid; or 4. the last day of the calendar month in which You are no longer a PEBB Eligible Retiree; or 5. the last day of the calendar month in which the Employer Group You were employed by ends participation in the WA State Health Care Authority PEBB or WA State Health Care Authority SEBB Group Plan for the group of employees You were included in prior to retirement. Please refer to the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOU for information concerning the option to convert to an individual policy of life insurance if Your Life Insurance ends. GCERT2024-WSHCA-WA-LIFE-RETIREE1 24
LIFE INSURANCE: FOR YOU If You die, Proof of Your death must be sent to Us. When We receive such Proof with the claim, We will review the claim and, if We approve it, will pay the Beneficiary the Life Insurance in effect on the date of Your death. PAYMENT OPTIONS We will pay the Life Insurance in one sum. Other modes of payment may be available upon request. For details, call Our toll free number shown on the Certificate Face Page. GCERT2024-WSHCA-WA-LIFE-RETIREE1 25
LIFE INSURANCE: CONVERSION OPTION FOR YOU If Your life insurance ends or is reduced for any of the reasons stated below, You have the option to buy an individual policy of life insurance (“new policy”) from Us during the Application Period in accordance with the conditions and requirements of this section. This is referred to as the “option to convert”. Evidence of Your insurability will not be required. When You Will Have the Option to Convert You will have the option to convert when: A. Your life insurance ends because: this Group Policy ends, provided You have been insured for life insurance for at least 5 continuous years; or this Group Policy is amended to end all life insurance for an eligible class of which You are a member, provided You have been insured for at least 5 continuous years; or B. Your life insurance is reduced due to an amendment of this Group Policy. If You opt not to convert a reduction in the amount of Your life insurance as described above, You will not have the option to convert that amount at a later date. Application Period If You opt to convert Your Life Insurance for any of the reasons stated above, We must receive a completed conversion application form from You within 60 days after the date Your Life Insurance ends or is reduced. Option Conditions The option to convert is subject to the following: A. Our receipt within the Application Period of: Your Written application for the new policy; and the premium due for such new policy; B. the premium rates for the new policy will be based on: Our rates then in use; the form and amount of insurance for which you apply; Your class of risk; and Your age; C. the new policy may be on any form then customarily offered by Us excluding term insurance; D. the new policy will be issued without an accidental death and dismemberment benefit, an accelerated benefit option, a waiver of premium benefit or any other rider or additional benefit; and nd E. the new policy will take effect on the 32 day after the date Your life insurance ends or is reduced; this will be the case regardless of the duration of the Application Period. GCERT2024-WSHCA-WA-LIFE-RETIREE1 26
LIFE INSURANCE: CONVERSION OPTION FOR YOU (continued) Maximum Amount of the New Policy If Your Life Insurance ends due to the end of this Group Policy or the amendment of this Group Policy to end all life insurance for an eligible class of which You are a member, the maximum amount of insurance that You may elect for the new policy is the lesser of: the amount of Your life insurance that ends under this Group Policy less the amount of life insurance for which You become eligible under any group policy within 31 days after the date insurance ends under this Group Policy; or $10,000. If Your life insurance ends or is reduced due to the Policyholder’s or Employing Agency’s organizational restructuring, the maximum amount of insurance that You may elect for the new policy is the amount of Your life insurance that ends under this Group Policy less the amount of life insurance for which You become eligible under any other group policy within 31 days after the date insurance ends under this Group Policy. If Your life insurance ends or is reduced for any other reason, the maximum amount of insurance that You may elect for the new policy is the amount of Your life insurance which ends under this Group Policy. ADDITIONAL PROVISIONS IF YOU DIE If You Die Within 60 Days After Your Life Insurance Ends Or Is Reduced If You die within 60 days after Your life insurance ends or is reduced by an amount You are entitled to convert, Proof of Your death must be sent to Us. When We receive such Proof with the claim, We will review the claim and if We approve it will pay the Beneficiary. The amount We will pay is the amount You were entitled to convert. The amount You were entitled to convert will not be paid as insurance under both a new individual conversion policy and the Group Policy. GCERT2024-WSHCA-WA-LIFE-RETIREE1 27
FILING A CLAIM CLAIMS FOR LIFE INSURANCE BENEFITS When there has been the death of an insured person, notify Us by calling 1-866-548-7139. This notice should be given to Us as soon as is reasonably possible after the death. The claim form will be sent to the beneficiary or beneficiaries of record. The beneficiary or beneficiaries should complete the claim form and send it and Proof of the death to Us as instructed on the claim form. When We receive the claim form and Proof, We will review the claim and, if We approve it, We will pay benefits subject to the terms and provisions of this certificate and the Group Policy. The benefit amount may be reduced by the amount of any due and unpaid contributions to premium outstanding at the time We make payment. GCERT2024-WSHCA-WA-LIFE-RETIREE1 28
GENERAL PROVISIONS Assignment The rights and benefits under the Group Policy are not assignable prior to a claim for benefits, except as required by law. We are not responsible for the validity of an assignment. Beneficiary You may designate a Beneficiary in Your application or enrollment form. You may change Your Beneficiary at any time. To do so, You must send a Signed and dated, Written request to Us using a form satisfactory to Us. Your Written request to change the Beneficiary must be sent to Us within 30 days of the date You Sign such request. You do not need the Beneficiary’s consent to make a change. When We receive the change, it will take effect as of the date You Signed it. The change will not apply to any payment made in good faith by Us before the change request was recorded. If two or more Beneficiaries are designated and their shares are not specified, they will share the insurance equally. If there is no Beneficiary designated or no surviving designated Beneficiary at Your death, We may determine the Beneficiary to be one or more of the following who survive You: 1. Your Spouse or State-Registered Domestic Partner; 2. Your biological child(ren), legally adopted child(ren), and stepchildren, including children of Your State- Registered Domestic Partner; 3. Your natural or adopted parent(s); or 4. Your sibling(s). Instead of making payment to any of the above, We may pay Your estate. Any payment made in good faith will discharge our liability to the extent of such payment. If a Beneficiary or a payee is a minor or incompetent to receive payment, We will pay that person's guardian. Entire Contract Your insurance is provided under a contract of group insurance with the Policyholder. The entire contract with the Policyholder is made up of the following: 1. the Group Policy and its Exhibits, which include the certificate(s); 2. the Policyholder's application; and 3. any amendments and/or endorsements to the Group Policy. Incontestability: Statements Made by You Any statement made by You will be considered a representation and not a warranty. We will not use such statement to avoid insurance, reduce benefits or defend a claim unless the following requirements are met: 1. the statement is in a Written application or enrollment form; 2. You have Signed the application or enrollment form; and 3. a copy of the application or enrollment form has been given to You or Your Beneficiary. We will not use Your statements which relate to insurability to contest life insurance after it has been in force for 2 years during Your life. In addition, We will not use such statements to contest an increase or benefit addition to such insurance after the increase or benefit has been in force for 2 years during Your life. GCERT2024-WSHCA-WA-LIFE-RETIREE1 29
GENERAL PROVISIONS (continued) Misstatement of Age If Your age is misstated, the correct age will be used to determine if insurance is in effect and, as appropriate, We will adjust the benefits and/or premiums to the amount of premium that would have been charged, or benefit that would have been provided, in the absence of the misstatement. Conformity with Law If the terms and provisions of this certificate do not conform to any applicable law, this certificate shall be interpreted to so conform. GCERT2024-WSHCA-WA-LIFE-RETIREE1 30
THE PRECEDING PAGE IS THE END OF THE CERTIFICATE. THE FOLLOWING IS ADDITIONAL INFORMATION.
If you disagree with a decision about your eligibility or enrollment for life insurance, visit www.hca.wa.gov/pebb-appeals for guidance on filing an appeal. If you disagree with any other decision concerning life insurance, contact MetLife at 1-866-548-7139.
Delaware American Life Insurance Company Metropolitan Life Insurance Company MetLife Health Plans, Inc. Metropolitan Tower Life Insurance Company MetLife Legal Plans, Inc. SafeGuard Health Plans, Inc. MetLife Legal Plans of Florida, Inc. SafeHealth Life Insurance Company Metropolitan General Insurance Company Our Privacy Notice We know that you buy our products and services because you trust us. This notice explains how we protect your privacy and treat your personal information. It applies to current and former customers. “Personal information” as used here means anything we know about you personally. SECTION 1: Plan Sponsors and Group Insurance Contract Holders This privacy notice is for individuals who apply for or obtain our products and services under an employee benefit plan, group insurance or annuity contract, or as an executive benefit. In this notice, “you” refers to these individuals. SECTION 2: Protecting Your Information We take important steps to protect your personal information. We treat it as confidential. We tell our employees to take care in handling it. We limit access to those who need it to perform their jobs. Our outside service providers must also protect it, and use it only to meet our business needs. We also take steps to protect our systems from unauthorized access. We comply with all laws that apply to us. SECTION 3: Collecting Your Information We typically collect your name, address, age, and other relevant information. We may also collect information about any business you have with us, our affiliates, or other companies. Our affiliates include life, car, and home insurers. They also include a legal plans company, and a securities broker-dealer. In the future, we may also have affiliates in other businesses. SECTION 4: How We Get Your Information We get your personal information mostly from you. We may also use outside sources to help ensure our records are correct and complete. These sources may include consumer reporting agencies, employers, other financial institutions, adult relatives, and others. These sources may give us reports or share what they know with others. We don’t control the accuracy of information outside sources give us. If you want to make any changes to information we receive from others about you, you must contact those sources. We may ask for medical information. The Authorization that you sign when you request insurance permits these sources to tell us about you. We may also, at our expense: Ask for a medical exam Ask for blood and urine tests Ask health care providers to give us health data, including information about alcohol or drug abuse We may also ask a consumer reporting agency for a “consumer report” about you (or anyone else to be insured). Consumer reports may tell us about a lot of things, including information about: Reputation Driving record Finances Work and work history Hobbies and dangerous activities The information may be kept by the consumer reporting agency and later given to others as permitted by law. The agency will give you a copy of the report it provides to us, if you ask the agency and can provide adequate identification. If you write to us and we have asked for a consumer report about you, we will tell you so and give you the name, address and phone number of the consumer reporting agency. CPN–Initial Enr/SOH and SBR (08/21) Page 1
Another source of information is MIB, Inc. (“MIB”). It is a not-for-profit membership organization of insurance companies which operates an information exchange on behalf of its Members. We, or our reinsurers, may make a brief report to MIB. If you apply to another MIB Member company for life or health insurance coverage, or a claim for benefits is submitted, MIB, upon request, will supply such company with the information in its file. Upon receipt of a request from you MIB will arrange disclosure of any information it may have in your file. Please contact MIB at 866-692-6901. If you question the accuracy of information in MIB’s file, you may contact MIB and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. You may do so by writing to MIB, Inc., 50 Braintree Hill, Suite 400, Braintree, MA 02184- 8734 or go to MIB website at www.mib.com. SECTION 5: Using Your Information We collect your personal information to help us decide if you’re eligible for our products or services. We may also need it to verify identities to help deter fraud, money laundering, or other crimes. How we use this information depends on what products and services you have or want from us. It also depends on what laws apply to those products and services. For example, we may also use your information to: administer your products and services process claims and other transactions perform business research confirm or correct your information market new products to you help us run our business comply with applicable laws SECTION 6: Sharing Your Information With Others We may share your personal information with others with your consent, by agreement, or as permitted or required by law. We may share your personal information without your consent if permitted or required by law. For example, we may share your information with businesses hired to carry out services for us. We may also share it with our affiliated or unaffiliated business partners through joint marketing agreements. In those situations, we share your information to jointly offer you products and services or have others offer you products and services we endorse or sponsor. Before sharing your information with any affiliate or joint marketing partner for their own marketing purposes, however, we will first notify you and give you an opportunity to opt out. Other reasons we may share your information include: doing what a court, law enforcement, or government agency requires us to do (for example, complying with search warrants or subpoenas) telling another company what we know about you if we are selling or merging any part of our business giving information to a governmental agency so it can decide if you are eligible for public benefits giving your information to someone with a legal interest in your assets (for example, a creditor with a lien on your account) giving your information to your health care provider having a peer review organization evaluate your information, if you have health coverage with us those listed in our “Using Your Information” section above SECTION 7: HIPAA We will not share your health information with any other company – even one of our affiliates – for their own marketing purposes. The Health Insurance Portability and Accountability Act (“HIPAA”) protects your information if you request or purchase dental, vision, long-term care and/or medical insurance from us. HIPAA limits our ability to use and disclose the information that we obtain as a result of your request or purchase of insurance. Information about your rights under HIPAA will be provided to you with any dental, vision, long- term care or medical coverage issued to you. You may obtain a copy of our HIPAA Privacy Notice by visiting our website at www.MetLife.com. For additional information about your rights under HIPAA; or to have a HIPAA Privacy Notice mailed to you, contact us at [email protected], or call us at telephone number (212) 578-0299. CPN–Initial Enr/SOH and SBR (08/21) Page 2
SECTION 8: Accessing and Correcting Your Information You may ask us for a copy of the personal information we have about you. We will provide it as long as it is reasonably locatable and retrievable. You must make your request in writing listing the account or policy numbers with the information you want to access. For legal reasons, we may not show you privileged information relating to a claim or lawsuit, unless required by law. If you tell us that what we know about you is incorrect, we will review it. If we agree, we will update our records. Otherwise, you may dispute our findings in writing, and we will include your statement whenever we give your disputed information to anyone outside MetLife. SECTION 9: Questions We want you to understand how we protect your privacy. If you have any questions or want more information about this notice, please contact us. A detailed notice shall be furnished to you upon request. When you write, include your name, address, and policy or account number. Send privacy questions to: MetLife Privacy Office P. O. Box 489 Warwick, RI 02887-9954 [email protected] We may revise this privacy notice. If we make any material changes, we will notify you as required by law. We provide this privacy notice to you on behalf of the MetLife companies listed at the top of the first page. CPN–Initial Enr/SOH and SBR (08/21) Page 3